Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology1
Epidemiology of Tuberculosis: Global, National & Wyoming
Randall Reves, MD, MScVolunteer Clinician Denver Metro TB Program and Division of Infectious Diseases, Department of MedicineUniversity of Colorado Denver
Disclosure
Randall Reves doses not have any financial disclosures.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology2
Brief reminder about TB: 19 y.o. student in septic shock in ED
Sudden onset of severe abdominal pain Negative past medical history except for
outpatient UTI treatment with ciprofloxacin 6 months earlier
Arrived in U.S. from Nepal in past year No known TB exposure, no prior + TST Chest X-ray “negative for TB” at prior
clinic visit, follow-up recommended but could not be accomplished
19 y.o. student in ED
•X-ray abnormalities?
•Diagnostic studies?
•Emergent treatment?
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology3
19 y.o. student in ED
Perforated colon at laparotomy
Granulomatous inflammation
Sputum AFB smear +
Expired despite I.V. levofloxacin, amikacin, rifampin & antibiotics
News Alerts
Colorado Springs Student From Nepal Dies From TBWoman Was International Student At CSU-PuebloPOSTED: 1:16 pm MDT June 11, 2007
COLORADO SPRINGS, Colo. -- Tuberculosis was confirmed as the cause of death of a patient who died at Colorado Springs' Memorial Hospital shortly after arriving at the emergency room on Friday.
It was not known what type of TB killed the 19-year-old student from Nepal but officials held an afternoon news conference to discuss the case.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology4
19 y.o. student: X-ray 6 mo earlier
Was TB the diagnosis then?
Was it partially treated with ciprofloxacin?
Was this illness and death preventable?
Reminder: TB can be deadly in healthy persons
Global TB Burden, 2016 estimates*
Estimated number of cases
Estimated number of deaths
1.7 million^• 1,070,000 in males
• 601,000 in women
• 253,000 in children
10.4 million140 per 100,000
• 6.7 million males
• 3.7 million females
• 1.4 million children
490,000 (4.1% of new TB)
600,000 (incl. RR‐TB)
Total TB
Multidrug‐resistant TBMDR/RR
HIV‐associated TB 1 million (10%) 374,000 (22%)
240,000(14%)
^Includes HIV/TB deaths*WHO Global TB Report 2017
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology5
WHO Global TB Report 2017 (for 2016)
30 high-burden countries: top 20 by number & top 10 by rates in smaller countries
For details see: http://www.who.int/tb/country/data/profiles/en/
WHO Estimated TB Incidence Rate, 2016
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology6
WHO Estimated TB Incidence, 2016
Global Impact of TB Deaths
WHO Global TB Report 2017
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology7
WHO Global TB Report 2017
WHO Global TB Report 2017
Global Trends in TB Incidence, Notification and Deaths
Notes: 39% of estimated TB not notified in 201686% of HIV deaths in African region
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology8
If this is true today, why is progress slowing?
We have yet to adequately respond -
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology9
Reported Tuberculosis (TB) Cases United States, 1982–2016*
*As of June 21, 2017.
No. o
f cases
Year
26,673 TB cases in 1992
9,272 TB cases in 2016
TB Morbidity United States, 2011–2017*
Year No. Rate
2011 10,509 3.4
2012 9,940 3.2
2013 9,561 3.0
2014 9,398 3.0
2015 9,547 3.0
2016 9,272 2.9
2017 9,092 2.8
*MMWR 3 23 2018: Decrease of 2.5% from 2016
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology10
TB Case Rates,* United States, 2016
*Cases per 100,000; as of June 21, 2017.DC, District of Columbia; NYC, New York City (excluded from New York state)
≤2.9 (2016 national average)
>2.9
DC
NYC
WY: Cases 1 & 4 in ’16 & ’15Rates 0.2 & 0.7
Map of U.S.‐Affiliated Pacific Islands, by TB Case Rates:* Total TB cases 471, pop. 3.8 million, rate 12.3 in 2016
*Cases per 100,000 population; as of June 21, 2017.
Federated States of
Micronesia
Marshall Islands
Northern Mariana Islands
American Samoa
Guam
Palau
≥5010–49.9≤9.9
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology11
TB Case Rates* by Age Group, United States, 1993–2016
*Cases per 100,000 population; as of June 21, 2017.
Cases per 100,000 population
Age (yrs.)
TB Case Rates by Age Group and Sex, United States, 2016*
*Cases per 100,000 population; as of June 21, 2017.
Cases per 100,000 population
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology12
TB Case Rates by Race/Ethnicity,* United States, 2003–2016†
* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† As of June 21, 2017.
Cases per 100,000 population
TB Case Rates by Age Group and Race/Ethnicity,*United States, 2016†
Cases per 100,000 population
* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† As of June 21, 2017.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology13
Number of TB Cases Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
No. o
f cases
*As of June 21, 2017.
Non‐U.S. born: 29.5% to 68.5% from 1994 to 2016
Reported TB Cases by Race/Ethnicity,*United States, 2016†
Hispanic/Latin 28%
Native Hawaiian/Pacific Islander 1%
American Indian/Alaskan Native 1%
Black/African American 21%Asian 35%
Multiple race 1%
White 13%
* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Percentages are rounded; as of June 21, 2017.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology14
Reported TB Cases by Origin and Race/Ethnicity*, United States, 2016†
U.S.‐born persons Non‐U.S.–born persons§
* All races are non‐Hispanic; multiple race indicates two or more races reported for a person, but does not include persons of Hispanic/Latino origin.† Percentages are rounded; as of June 21, 2017.§ American Indian/Alaska Native accounted for <1% of cases among non‐U.S.–born persons and are not shown.
TB Case Rates Among U.S.‐Born versus Non‐U.S.–Born Persons, United States*, 1993–2016†
Cases per 100,000 population
* Includes the same data as previous slide, but rates are presented on a logarithmic scale.† As of June 21, 2017.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology15
Countries of Birth Among Non‐U.S.–Born Persons Reported with TB, United States, 2016
*Percentages are rounded; as of June 21, 2017.
Primary Anti‐TB Drug Resistance, United States, 1993–2016*
* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB; multidrug‐resistant TB (MDR‐TB) is defined as resistance to at least isoniazid and rifampin.
Resistan
t (%
)
Year
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology16
Primary MDR‐TB, United States, 1993–2016*
* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB; multidrug‐resistant TB (MDR‐TB) is defined as resistance to at least isoniazid and rifampin.
Primary Isoniazid Resistance Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
Resistan
t(%
)
* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB.
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology17
Primary MDR‐TB Among U.S.‐Born versus Non‐U.S.–Born Persons, United States, 1993–2016*
* As of June 21, 2017. Note: Based on initial isolates from persons with no prior history of TB; multidrug‐resistant TB (MDR‐TB) is defined as resistance to at least isoniazid and rifampin.
Resistan
t(%
)
Epidemiology of MDR TB in the U.S.
168 cases in 8 states, 86% foreign-born, 15% with clustered isolates by genotyping
92 in-depth interview: 22% imported active MDR TB (within 3 mo.)
22% due to transmission within USA
41% due to reactivation of latent TB infection, with 15% previously treated outside USA
5% relapse of TB previously treated in USA
10% unknown
Moonan P, et al Lancet Infection 2013: TBESC TO 8
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology18
XDR‐TB* Case Count, Defined on Initial DST,†
by Year, 1993–2016§
* XDR‐TB , extensively drug‐resistant TB.† DST, drug susceptibility test.§As of June 21, 2017.Note: XDR‐TB is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second‐line anti‐TB drugs.
Case count
Year of diagnosis
US-born and Foreign-born Prevalence of LTBI & Case Rates by Age,
1999-2000 Bennett 2007, CDC 2000LTBI Prevalence
0.3 0.6 1.23.4 4.8
11.9 12.8
20.6
25.3
11.9
0
5
10
15
20
25
30
< 15 15- 25- 45- 65+
%
US-B FB
TB Case Rate
1.3 1.4 3.6 5.88.37.3
19.9 19.122
35.8
05
10152025303540
<15 15- 25- 45- 65+
Rate
US-B FB
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology19
Estimated TB Infection in the U.S.LTBI prevalence 6 million to 13 million.
Foreign born TST 20.5%
QFT 15.9%
Both positive 9.3%
US-born
TST 1.5%
QFT 2.8%
Both positive 0.6%
Reported TB 9 years in WY’ 2009-17
Cases: 25, range 0 (’13) -7 (’10), ave 2.8
Nativity (missing 3): US 8
Africa 2: Ethiopia, Kenya
Asia 7: China, India, Nepal 3, Philippines 2
Latin America 5: Mexico 3, Peru 2
Site (missing 1): Pulmonary 17
Extra-pulmonary 7
Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center
Epidemiology20
How can you use epidemiologic data in the clinic? What questions are more important in assessing a patient’s risk of TB?
Country of birth or length of residence in a TB-endemic country?
Age or years of residence in TB-endemic country?
Race/ethnicity or country of birth/residence?